tional or other resources. Evidence continues to mount that one of the more promising strategies to prevent States Using Evidence-Based child are home visitation programs, especially those that use nurses. The Centers Methods to Prevent for Disease Control and Prevention (CDC) Task Force on Community Preventive Infant found strangled. Young father found and keep children and families out of the Services recently reviewed published studies guilty in the beating death of his toddler. Inno- child welfare system. The question is: how and found that such programs reduced child cence lost. Child abuse off the charts. do we achieve this? abuse or by about 40 percent. When News headlines from across the nation delivered by professionals – nurses or mental draw attention to the plight of abused and PREVENTING ABUSE: WHAT WORKS? health workers – the programs “yielded more neglected children. While the media focus There are hundreds of child abuse pre- beneficial effects than did those delivered by on the extreme cases, hundreds of thousands vention programs around the country, with paraprofessionals,” such as volunteers. of children – 860,000 in 2002 alone – were the most prevalent being group-based par- The report concluded, “On the basis of victims of some form of abuse, chiefly, ne- ent education, home visitation and family re- strong evidence of effectiveness, the task force glect. About 1,400 children, most of them source centers. With few funds to spare, states recommends early childhood home visitation younger than four, died at the hands of their and localities want to invest their dollars in for prevention of child abuse and neglect in parents or caretakers. For many children, the programs that have a sound scientific base. families at risk for maltreatment, including first day of life is the most dangerous, as un- Research has shown that effective pro- disadvantaged populations and families with wanted infants may be abandoned or killed. grams intervene with children and families low-birth weight infants.” The second “peak” is at eight weeks, when very early on – prenatally or at birth; are long- One of the most effective programs re- daily intense crying is at its highest for most term and intensive; and offer parents help viewed by the CDC was established by Dr. normal infants. with finances, health care and mental health David Olds at the University of Colorado. The long-term consequences of child issues, according to Dr. Deborah Daro, an Olds’ project used public health nurses to abuse are enormous. Abused and neglected expert in child abuse treatment and preven- provide at-home, intensive, long-term ser- children are at higher risk for poor health tion at the Chapin Hall Center for Children vices to low-income, at-risk pregnant women outcomes, mental health disorders, language at the University of Chicago. Such programs bearing their first child. In a 15-year follow- deficits, reduced cognitive functioning, poor offer direct services for children and are linked up, researchers found that participants in school performance, substance abuse in later to other services that support families. Effec- the Olds project experienced 79 percent life, criminality, teen pregnancy and of be- tive programs also limit the caseloads for child fewer child abuse reports, 31 percent fewer coming abusers themselves to future genera- abuse prevention program staff to no more births and 69 percent fewer maternal arrests, tions. The financial costs are in the tens of than 15 families per worker, hire staff with compared to their counterparts in a control billions of dollars. They include child welfare strong relationship-building skills and pro- group who did not receive project services. services (child protection, foster care and vide ongoing training and supervision. Their 15 year-old children experienced 56 adoption), substance abuse and mental health Programs with these elements reduce the percent fewer arrests and 56 percent fewer treatment, law enforcement and medical occurrence and intensity of child abuse, im- days of alcohol consumption, compared to treatment for injuries. Society also pays for prove interactions between parent and child, controls. costs associated with homelessness, welfare enhance child development and link families Olds’ project was one of the first scien- dependency and unemployment. to much needed health-care services, Daro said. tifically controlled studies of this type of child It’s no surprise that states and localities She cautioned, however, that not all pro- abuse prevention. Based on these findings, are struggling to “fix” the child welfare sys- grams will work all the time for all families. the Center for the Study and Prevention of tem, increase penalties for perpetrators of One-third of families offered voluntary ser- Violence at the University of Colorado at abuse and move children more quickly out vices refuse to participate. And even a well- Boulder designated the Olds strategy of of foster care and into permanent homes. designed program can make little progress nurse-family partnerships as a model program However, most experts agree that stopping with families if the health-care system is in- for violence prevention. Currently, some child abuse before it occurs would save lives adequate and there are few economic, educa- 14,000 children are engaged in nurse-family

CONTRIBUTING STAFF partnership projects in 22 states. Glen Andersen, Steve Christian, Allison Cook, Carla Curran, Jo One of those states is Wyoming, which is produced by staff from the Environment, Energy and Donlin, Doug Farquhar, Shannon Harper, Tracey Hooker, in 2000 allocated $2 million to create the Transportation Programs and the Health Care and Martha King, Jeane Kaurman, Leslie Teach Robbins, Hy Gia Prevention Projects Programs, located at the Park, Jody Ruskamp, Lisa Speissegger, Laura Tobler, Stephanie Public Health Nursing Infant Home Visita- National Conference of State Legislatures Wasserman, Nina William-Mbengue, Amy Winterfield headquarters in Denver. tion program. Based on the nurse-family part- 700East First Place Denver, CO 80230 nership model, the program targets low-in- For more information about the programs, visit: Fax: (303) 364-7800 http://www.ncsl.org or call (303) 364-7700. come, pregnant women and families with in- email: [email protected] or [email protected] This insert is supported in part by grants from the Centers for Disease Control and Prevention and fants, incarcerated women, women with his- the Health Resources and Services Administration, U.S. Department of Health and Human Services tories of substance abuse or mental illness, and

STATE HEALTH NOTES - MAY 3, 2004 1 A Ph.D. psychologist, John R. Lutzker is one in the urban San Fernando valley of Los An- of the nation’s premier experts in preventing child geles, and our population was far more di- maltreatment. Currently, he is in charge of devel- verse in California, with the primary recipi- oping and evaluating violence prevention pro- ents of the services being Latinos. grams for the Centers for Disease Control and LUTZKER:PREVENTING We labeled the services in Project Prevention (CDC). Lutzker has published over CHILD MALTREATMENT SafeCare “bonding,” which is a systematic 100 professional articles and chapters, and is the vacuums. That means, if we are going to be form of parent training, parent/child behav- author of five books, including Reducing Child effective in dealing with child maltreatment, ior management training for the parent, health- Maltreatment: A Guidebook for Parent Services. we need to deal with the entire social ecol- care skills for the parent for their children, and He is a recent recipient of the James M. Gaudin ogy such as the parent/child relationship, teaching home safety and home cleanliness. In Outstanding Research Award from the Georgia advocacy for the child, community resources neglect families, who are the majority of fami- Professional Society on the Abuse of Children. and so forth. seen in child maltreatment referrals, often Q: What is the CDC doing to help states Other models rely exclusively on assess- the very poor health and safety conditions of implement effective child maltreatment preven- ments such as rating scales or self-reports. In the home are the reason for the referrals. So the tion programs? the ecobehavioral model, families are observed goal there is to teach families the skills they A: We are involved in many activities and taught right in the home and other set- need to make the environment much safer and that will help states protect children. For ex- tings. The ecobehavioral model is designed to healthier for their children. ample, we are currently developing uniform try to teach families skills that they have not After three years, the SafeCare families definitions and data elements for child mal- been shown before, so that they can use those survived at a nearly 90 percent level, mean- treatment surveillance. Without uniform defi- skills with new challenges in new settings. So ing there were no further reports of child mal- nitions, different terms are used to describe we might teach the family in the home, or we treatment, whereas only 56 percent of the acts of maltreatment, and these inconsisten- might teach them on a car ride or in a grocery families who received traditional treatment cies contribute to confusion and a lack of con- store, with the hope that they can then gener- only had no further incidents. Statistically, sensus about the magnitude of the problem. alize those skills to other situations. We try to that is a highly significant rate. We also have funded 13 states to estab- teach skills that over time become durable. Q: What recommendations do you have for lish a National Violence Death Reporting The ecobehavioral model does raise some state officials who are trying to prevent child System, which will enable them to share and tricky issues. There’s a delicate balance be- neglect and abuse? link state-level data about violence, includ- tween intrusiveness and help. We want to A: There are three key recommendations. ing homicide, suicide, undetermined and un- assess the families as often as possible, but we First, if they are involved in evaluating a pro- intentional deaths. The reporting system will have to be careful not to become too intru- gram, they should affiliate with very solid enable us to gain much more accurate and sive – parents might drop out. research teams. These should be teams with in-depth information about victims of child Q: How did the ecobehavioral model be- considerable expertise in evaluation and a maltreatment and abuse-related deaths. gin? And is it catching on? record of producing publishable outcomes. Separately, the health departments of A: The first ecobehavioral project began Another recommendation would be that California, Michigan, Minnesota, Missouri in 1979. I wrote a grant when I was with the states adopt programs that have been shown and Rhode Island are comparing alternative University of Southern Illinois, starting some- scientifically to be effective. They should approaches to surveillance for fatal and non- thing called Project 12-Ways. Project 12- evaluate and adopt only evidence-based pro- fatal childhood maltreatment, and testing Ways has been ongoing since July 12, 1979, grams – that can’t be stressed enough. Many methods to survey violence at all ages. served over 1,500 families, brought in over programs look good cosmetically, but if you And, we’re involved in something called $12 million dollars, and trained hundreds look closely at their evaluations, those turn ICARUS, a periodic in-depth injury survey. of developing professionals. The referrals to out to be self-evaluations or testimonials. Such In the next one, we’ll ask the public about Project 12-Ways are rather homogeneous programs should be avoided, especially if the their willingness to pay to prevent a case of and are exclusively through the Illinois De- states plan to implement them on a large scale. childhood maltreatment. When we have partment of Human Services. By homoge- Finally, I would suggest that once states those data, we’ll be able to conduct much neous, I mean that the demography of choose a program, that they start small. Un- more sophisticated cost-benefit analyses on southern Illinois is largely white poor fami- less it has been proven that the program can child maltreatment prevention programs. lies in rural circumstances. We have data over be disseminated widely, states should test one That should help the states a great deal in the years to suggest that Project 12 –Ways is or two regions or something very minimal, finding out which programs provide the most more effective than other services in the same get some very good data, and make sure that benefit for the funding dollar. region offered to families. the services that are delivered are the ones Q: You have referred to the SafeCare project That led to a grant from the California that were prescribed. Then, if the outcome in Oklahoma as an “ecobehavioral” model. Just Wellness Foundation to systematically repli- data look good to “scale up,” start expanding what do you mean by that? cate Project 12-Ways in California. In doing gradually. If you have outcomes data that A: The ecobehavioral model basically so, we labeled the program Project SafeCare. show the program is cost-effective, then stems from the belief that families are social It was different from Project 12-Ways in a you’ve got a really robust argument for dis- ecologies, they are not simply individuals in number of ways. First of all, we conducted it seminating or replicating programs. NWM

2 STATE HEALTH NOTES - MAY 3, 2004 Child Maltreatment

Rate of Child Victims by State, 2002

Victims per 1,000

0.0 to 6.0

6.1 to 14.0

14.1 to 20.00

Greater than 20

Perpetrator Status, 2002 FAST FACTS:

In 2002, an estimated 896,000 Mother Only 40.3 children nationwide (12.3 per 1,000) Father Only 19.1 were found to be victims of maltreat- Mother and Father 18 ment. Mother and Other 5.4 · 60% of these victims experienced Father and Other 1 Nonparental 13 neglect (including medical neglect) Perpetrator Unknown 3.2 ·18.6 % were physically abused Missing 0 5 10 15 20 25 30 35 40 45 · 9.9 % were sexually abused Percent of Victims · 6.5 % were emotionally or Source: Child Maltreatment 2002, U.S Department of Health and Human Services, psychologically mistreated Administration for Children and Families.

STATE HEALTH NOTES - MAY 3, 2004 3 victims of . Public health safety, but it provides services for underlying lies who participated in an intensive early nurses provide “welcome home” visits, infor- issues as well, such as counseling for mental childhood intervention program run by Chi- mation on infant care, service referrals and a illness and substance abuse. Services that cago public schools had a 52 percent lower thorough assessment of the infant’s circum- might otherwise be fragmented and difficult rate of maltreatment than did those who did stances. The families receive services up until to obtain thus become coordinated. not. Children enrolled in the program for the infant’s 24th month. The pilot project will be tested through more than four years experienced an even Wyoming is not alone in its efforts to a randomized trial. Families will either receive lower rate of maltreatment. The benefits were meld effective, research-based programs with Project SafeCare services or a mix of standard greatest when the children were between 10 strategies to prevent child abuse. In 2001, services, such as substance abuse counseling, and 17 years old. the Oklahoma Legislature passed House Bill mental health and parenting education. 1143, which sets up a pilot project to iden- In addition to evaluating the House Bill MIAMI SAFE START tify children at high risk of abuse and to test 1143 project, the CDC and its Oklahoma In Florida, the 11th Circuit Juvenile methods of helping those children. partners will conduct a four-year evaluation Court of Miami-Dade County, the state Leg- “When I became a legislator, I decided to of Project SafeCare in a larger-scale, statewide islature and prevention/early intervention request funds for a pilot project to develop a randomized trial. Three of the state’s six re- services have joined to help court-involved model that would work for children and fami- gions will receive Project SafeCare services and families. Funded by the state Legislature in lies at highest risk for child abuse,” explained the other three will receive enhanced “services 2000, the Miami Safe Start project provides bill sponsor Rep. Ron Peters. “I felt that if as usual” in an effort to determine which route maltreated children under three with assess- you’re going to spend government money, it is most effective at preventing maltreatment. ments and referrals to early intervention ser- has to be spent on programs that work.” vices. Mothers and children who become in- The legislation requires the partners to WORKING WITH CHILD CARE volved in the justice system receive services develop services for high-risk children, coor- Another new approach to preventing that focus on attachment and other develop- dinate state and local services for these chil- child abuse is to use early care and education ment issues. The project videotapes mother dren and their families, and include both settings. Through a grant from the Doris and child interactions and uses standard as- urban and rural concerns. A board, compris- Duke Foundation, the Center for the Study sessment tools to refer families to needed ser- ing representatives from the Legislature, the of Social Policy (CSSP) recently identified 21 vices to prevent further maltreatment. Governor’s office, departments in the state “exemplary” early child-care programs that The pilot project subsequently collabo- administration, the Oklahoma Indian Affairs work with families to reduce child abuse. rated with the local Early Head Start agency Commission and the CASA Association, is to These programs help parents develop and the University of Miami’s Linda Ray In- evaluate the project and report back to the parenting skills, understand child develop- tervention Center to become the nation’s first Legislature by May 2005. ment, and access community and social sup- juvenile court-sponsored early head start pro- The provider agency selected to conduct ports. They may also provide concrete finan- gram. Funded by the Office of Juvenile Jus- the pilot approached the CDC to identify cial and other assistance in times of need. tice and Delinquency Prevention at the U.S. effective prevention programs. The agency The rationale is that millions of children Department of Justice, the now-expanded chose Project SafeCare, a home visiting pro- and families enroll in child-care programs, so program provides children and their caretak- gram -- orginally developed in Illinois and using them to prevent maltreatment could ers with the services offered in the pilot. California -- that has proven effective in re- help large numbers of children. Also, families Florida State University is evaluating the ducing subsequent reports of suspected mal- tend to develop long-term relationships with project. Baseline data collected so far docu- treatment and in preventing neglect. their child-care providers, and they often ments the factors that put families at risk for Project SafeCare is different from stan- share information about their family life that maltreatment: birth complications, language dard child abuse prevention programs in that they would not ordinarily share with gov- delays, mental disorders, unemployment, it provides at-risk families with comprehen- ernment intervention services. Child-care pro- drug/alcohol abuse and prior jail experience. sive, intensive services. Most of the families viders see families and children up close and Setting out to prevent child maltreat- in the pilot project struggle with drug and/or can act as an early warning system for families ment can be a daunting prospect, given all alcohol abuse, mental or physical disabilities, in trouble. the factors that come into play. But working and intimate partner violence. Project Research from the University of Wiscon- with partners in innovative ways, states are SafeCare not only provides education about sin appears to support the CSSP premise. Re- finding that there is much they can do to basic parenting, child development and searchers there found that low-income fami- protect the youngest Americans. NWM

RESEARCH & EDITORIAL STAFF ADVISORY BOARD HEALTH POLICY TRACKING SERVICE Dick Merritt Forum Director Rep. Fran Bradley, Minnesota M. Lee Dixon HPTS Director Christina Kent Managing Editor Rep. Charlie Brown, Indiana Staff: Patrick Johnson, Andrew McKinley, Carla Anna C. Spencer Associate Editor Rep. Dianne White Delisi, Texas Plaza, Rachel Tanner Contributors: Allison Colker, Donna Folkemer, Kurt DeWeese, Speaker’s staff, Illinois Published biweekly (24 issues/yr.) by Rep. Peter Ginaitt, Rhode Island the FORUM FOR STATE HEALTH Wendy Fox-Grage, Shelly Gehshan,Tim Henderson, Michelle Herman, Diana Hinton, Kala Del. Marilyn Goldwater, Maryland POLICY LEADERSHIP, an Sen. Kemp Hannon, New York information and research center at the Ladenheim, Greg Martin, Anna B. Scanlon John Kasprak, Senior Attorney, National Conference of State Legislatures Connecticut Legislature in Washington, D.C. EDITORIAL INQUIRIES Sen. William Martin, North Carolina For more information about Forum Christina Kent, Managing Editor Sen. Pat Thibaudeau, Washington CUSTOMER SERVICE & SUBSCRIPTIONS projects, visit our Web site at: Tel: 202-624-5400 • Fax: 202-737-1069 Sen. Maggie Tinsman, Iowa NCSL, 7700 East First Place, Denver, CO 80230 www.ncsl.org/programs/health/forum email: [email protected] Tel: 303-364-7700 • Fax: 303-364-7800

4 STATE HEALTH NOTES - MAY 3, 2004